High School Counseling Referral 23-24

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

If you would like to see your counselor, please fill out the following referral form. This form is confidential. A counselor will call you down as soon as possible. If this is urgent, please go to the office immediately. If this is an emergency, please call 9-1-1.

**DO NOT USE THIS FORM FOR SCHEDULE CHANGES. Use the schedule change form HERE.

Email *

What is your name? *

What is your grade? *

Freshman 9

Sophomore 10

Junior 11

Senior 12

Which counselor is this referral for?

Mrs. Conrad (Last names A-F)

Mrs. Hirst (Last names G-O)

Mr. Pressuer (Last names P-Z)

Mrs. Kost (Prevention)

Clear selection

What is the best time for you to meet?

Academic Class

Elective Class

Lunch

Before School

After School

Other:

Clear selection

How Can We Help? Please check all that apply.

Academic Concern

College/Career

Peer Relationships

Personal/Family

Mistreatment/Bullying

Class Planning

Other:

Additional information/comments

Submit

Clear form

Never submit passwords through Google Forms.

This form was created inside of Cloverleaf Local School District. Report Abuse

Forms